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WAhospital2024-04-10

Inquest into the Death of Alan David RATCLIFF

65y · Male·complications of intracranial haemorrhage (hypertensive haemorrhage), with termi…

Alan David Ratcliff, a 65-year-old prisoner at Acacia Prison, died from complications of intracranial haemorrhage (hypertensive haemorrhage) on 20 June 2022. He collapsed on 12 June 2022 with stroke symptoms and was hosp…

neurologyemergency medicinedelay
WAhospital2024-04-08

Inquest into the Death of Child SK (Name Subject to Suppression Order)

13y · Female·complications of a head injury sustained when she deliberately stepped in front …

A 13-year-old with emerging emotionally unstable personality disorder (EUPD) died by suicide after deliberately stepping in front of a car on 21 July 2020, two days after a positive appointment with mental health clinici…

psychiatryemergency medicinesystemdelaysertraline
WAhospital2024-04-04

Inquest into the Death of Karl Frederick Dominic HOLMES

66y · Male·Complications of metastatic lung adenocarcinoma, with terminal palliative care, …

Karl Frederick Dominic Holmes, a 66-year-old prisoner with metastatic lung adenocarcinoma and hepatocellular carcinoma, died from complications of his terminal cancer while serving a 7-year sentence. He received excellen…

oncologypalliative caresystemdelaymorphine
WAprison2024-02-21

Inquest into the Death of Iain Campbell BUCHANAN

65y · Male·complications, including pneumonia, of traumatic brain injury

A 65-year-old male prisoner died from complications of severe traumatic brain injury sustained when punched by another prisoner at Hakea Prison. He fell backwards, striking his head, and was assessed at the prison medica…

neurosurgeryemergency medicinedelaysystem
WAhospital2024-01-12

Inquest into the Death of Herbert William MACKAY

45y · Male·complications associated with metastatic adenocarcinoma of the lung, treated pal…

Herbert Mackay, a 45-year-old Aboriginal man, died from complications of metastatic adenocarcinoma of the lung discovered at stage 4 in late December 2020 while imprisoned at Casuarina Prison. He presented with respirato…

oncologycardiothoracic surgery
WAhospitalAugust 2023

Inquest into the Death of Justin DOBSON

46y · Male·sepsis following haemorrhoidectomy

46-year-old Justin Mark Dobson died from sepsis following a routine haemorrhoidectomy on 17 July 2019. He was discharged to the ward overnight but deteriorated significantly from 11:00 am on 18 July, showing hypotension,…

general surgerycolorectal surgerydiagnosticcommunicationmetronidazole
WAhospital2023-12-13

Inquest into the Death of Ashleigh Rebecca HUNTER

26y · Female·meningococcal infection (Neisseria meningitidis W strain) causing septicaemia

Ashleigh Rebecca Hunter, a previously healthy 26-year-old, died from meningococcal septicaemia (W strain) within 3 hours of arriving at Royal Perth Hospital. She presented with severe generalised pain (10/10), tachycardi…

emergency medicineinfectious diseasesdiagnosticsystemMDMA
WAhospital2023-11-29

Inquest into the Death of Samuel Edward ASHBY

46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…

Samuel Edward Ashby, a 46-year-old prisoner with treatment-resistant schizophrenia, died from aspiration pneumonia complicated by clozapine effect. Key clinical lessons: (1) smoking cessation dramatically increases cloza…

psychiatrygeneral medicinediagnosticsystemclozapine
WAhospital2023-11-17

Inquest into the Death of Child MD (Name Subject to a Suppression Order)

2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…

A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…

intensive carepaediatricsmedicationceftriaxone
WAhospital2023-11-02

Inquest into the Death of Bradley James Raymond STINSON

66y · Male·Cardiac arrhythmia in a man with arteriosclerotic cardiovascular disease, pulmon…

Bradley Stinson, a 66-year-old prisoner with a long history of heavy smoking and alcohol use, died from cardiac arrhythmia in the setting of arteriosclerotic cardiovascular disease, pulmonary thromboembolism, and metasta…

palliative careoncologyproceduralsystemoxycodone
WAcommunity2023-10-20

Inquest into the Death of Ashley Dean FILDES

34y · Male·gunshot injuries to the torso

Ashley Fildes, a 34-year-old man with schizophrenia, was fatally shot by police on 1 May 2020 after stabbing multiple people at a shopping centre while in acute psychosis. He had been non-compliant with depot antipsychot…

psychiatryemergency medicinepaliperidone depot
WAaged care2023-10-11

Inquest into the Death of Kathryn PAPANASTASIOU

74y · Female·Fractures of the legs, with terminal palliative care, in an elderly lady with mu…

Ms Papanastasiou, a 74-year-old aged care resident confined to a wheelchair, died from bilateral femoral fractures sustained when she fell from her wheelchair during sudden bus braking. The wheelchair was secured using o…

geriatric medicineorthopaedic surgerysystemprocedural
WA2023-09-14

Inquest into the Death of Shane Reynold NARRIER

40y · Male·coronary artery atherosclerosis

Shane Narrier, a 40-year-old Aboriginal man, died from coronary artery atherosclerosis on 5 June 2020 at Acacia Prison. On 27 May 2020, he reported chest pains via the Custody Messaging System (CMS) to a prison nurse. Th…

cardiologyemergency medicinediagnosticcommunicationescitalopram
WAhome2023-07-14

Inquest into the Death of Matthew James WORTHINGTON

Male·Gunshot injury to the head

Matthew Worthington died from a self-inflicted gunshot wound to the head during a 21-hour police siege at his home in Bayswater, Western Australia, on 24 November 2020. He was experiencing a relationship breakdown, had r…

emergency medicineintensive caremethamphetamine
WAhospital2023-06-29

Inquest into the Death of Child R (Name Subject to Suppression Order)

11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…

Child R, an 11-year-old Aboriginal girl with congenital anorectal anomalies causing chronic severe constipation, presented to Halls Creek Hospital on 5 January 2017 with severe abdominal pain and vomiting. She died 12 ho…

paediatricsemergency medicinediagnosticcommunicationmacrogol
WAhospital2023-05-26

Inquest into the Death of Jacob George Isaac TAULELEI

28y · Male·Multiple injuries sustained when struck by a freight train

Jacob Taulelei, a 28-year-old man with long-standing depression, anxiety, and suicidal ideation, presented to St John of God Hospital on 5 February 2020 expressing intent to jump in front of a train. Despite being assess…

psychiatryemergency medicinediagnosticcommunicationduloxetine
WAhospital2023-03-30

Inquest into the Death of Hugh WARD

89y · Male·Complications of cerebrovascular accident (stroke); specifically a catastrophic …

Hugh Ward, an 89-year-old sentenced prisoner, died from complications of stroke following an embolic cerebrovascular accident at Sir Charles Gairdner Hospital. While incarcerated, Mr Ward had multiple comorbidities inclu…

neurologycardiologycommunicationsystemwarfarin
WA2023-03-13

Inquest into the Death of Frank ALBERT

46y · Male·atherosclerotic heart disease

Frank Albert, a 46-year-old Aboriginal man, died from atherosclerotic heart disease while incarcerated at West Kimberley Regional Prison. Although his death was caused by severe coronary artery disease unrelated to medic…

cardiologyemergency medicinesystemcommunicationquetiapine
WAcommunity2023-02-28

Inquest into the Death of Paul James BRADY

35y · Male·multiple injuries

Paul James Brady, aged 35, died from multiple injuries sustained after jumping from a third-floor apartment balcony on 15 May 2020. Two police officers arrived at the scene within minutes of receiving a call about a man …

emergency medicineforensic medicineproceduraldelaytemazepam
WAhospital2023-02-22

Inquest into the Death of Aishwarya Aswath CHAVITTUPARA

7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)

7-year-old Aishwarya Aswath Chavittupara died from multiorgan failure due to fulminant sepsis (Streptococcus pyogenes) after approximately 90 minutes in Perth Children's Hospital emergency department. She presented with …

emergency medicinepaediatricsdiagnosticcommunication

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